Transcatheter Fibrinolytic Therapy and Angioplasty for Left Iliofemoral Venous Thrombosis

Abstract

© SCVIR, 1991 CASE REPORT A 29-year-old woman presented with progressive painful swelling of the left leg during the preceding week. Her pertinent medical history included a hysterectomy 1 month earlier for pelvic pain. She had used birth control pills and smokes one pack of cigarettes per day. Doppler studies performed on admission revealed thrombosis of the left common femoral vein, left superficial femoral vein, and left popliteal vein. The patient was admitted immediately, and routine systemic administration of heparin was begun. As we anticipated the need for transcatheter thrombolytic therapy, a left antecubital approach was used to deliver a 4-F multiple-side-hole catheter into the left external iliac vein. A digital subtraction venogram demonstrated iliofemoral venous thrombosis (Fig 1). Heparin was discontinued at the time of antecubital vein puncture. Laboratory data at initial examination included a normal complete blood count, a partial thromboplastin time of 25.3 seconds (normal, 20-30 seconds), fibrin degradation product levels of 2-10 JLg/mL (normal, 2-10 JLg/mL), a fibrinogen level of 310 mg/ dL (3.1 gIL) (normal, 250-500 mg/dL [2.5-5.0 gIL]), and a platelet count of 357 X 10/mm (357 X 1091L) (normal, 150 X 103_ 600 X 103/mm3 [150 X 109600 X 1091L]). Prothrombin time, partial thromboplastin time, and fibrinogen levels were measured every 8 hours thereafter. Urokinase therapy was initiated through the catheter placed for the diagnostic study as a bolus of 250,000 IU followed by a continuous infusion of 150,000 IU/h. A total of 7 million IU of urokinase was administered over a period of 48 hours. Twenty-four hours after initiation of therapy, recanalization of the left external iliac vein was demonstrated with some residual thrombus and persistent left common femoral thrombosis (Fig 2). The 4-F catheter was exchanged for a 5-F multipleside-hole catheter and was advanced into the left common femoral vein. Injection of contrast material into the catheter at 36 hours after initiation of therapy demonstrated improvement in the iliac vein but persistent left common femoral vein thrombosis. The infusion catheter was then advanced further into the thrombus in the left superficial femoral vein. Contrast material injection at 48 hours revealed no significant improvement, and the urokinase delivery rate was increased to 250,000 IU/ h. After 60 hours of urokinase therapy, the catheter was inadvertently displaced in the inferior vena cava and was repositioned under fluoroscopic control into the left superficial femoral vein. On the final day of infusion, the partial thromboplastin time peaked at 59 seconds, the prothrombin time peaked at 17 seconds (normal, 11-14 seconds), and the fibrinogen level decreased to 155 mg/dL (1.55 gIL). The course of the infusion was uneventful. Sixty-eight hours following the initiation of thrombolytic therapy, the venogram obtained through the catheter demonstrated persistent webs within the vein and an oblique filling defect suggestive of a crossing vessel (Fig 3). Pressure measurements were not obtained. Injection of contrast material into the infusion catheter revealed that clot lysis had occurred in the iliac venous system. Doppler studies demonstrated restored venous patency of the left popliteal and left superficial femoral vein (Fig 4).